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Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds

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Posted 2/17/2011 5:51 PM (GMT 0)
Another article stressing expereince

http://www.bloomberg.com/news/2011-02-16/doctors-need-1-600-robot-aided-prostate-surgeries-for-skills-study-finds.html

 

Posted 2/17/2011 6:01 PM (GMT 0)
"While he hasn’t yet seen the study, the 1,600 number “strikes me as absurd,” Darling said today in a telephone interview.
Training Time

“The average time it takes to get to proficiency as defined by our hospitals in their training protocols is typically mid- double digits,” he said. “This is an order of magnitude higher.” "

I must agree with Darling...If they haven't learned how to do it in 300 tries, they will NEVER learn how to do it..
Posted 2/17/2011 6:07 PM (GMT 0)
SHU,
Great timing on the post. The oncologist at the end of the article, Nick Vogelzang, is my primary captain of my prostate cancer ship. Over the next few months at our UsTOO group I have arranged a series of guest speakers speaking on specific treatment modalities. And in about four hours I am headed to the airport to pick up my guest speaker for tonights theme ~ Radical Prostatectomy. My guest speaker has also been on my team ~ Dr. Tim Wilson from the City of Hope. He has more than 2,000 DaVinci surgeries under his belt (or is that under our belt?). Next month I have A special session on the state of prostate cancer medical oncology where Nick Vogelzang will present his ASCO presentation that he is doing today in Orlando on the matter. The following month is dedicated to radiation where I have another gem of a doctor in Brian Lawenda speaking.

Tony
Posted 2/17/2011 6:32 PM (GMT 0)
My first thought was that if it takes 1600 surgeries to be proficient, then think of the human debris these surgeons have left in their wake during the first 1599.  If this is true, perhaps we should ban the DaVinci machine and revert to doing only open surgeries.

A relative of mine will in all likelihood be having surgery next month by a surgeon who has "only" about 300 DaVinci procedures under his belt.  What a shame!

My uro/surgeon had about 50 surgeries and seems to have done a first-rate job.

If I had read something like this prior to surgery, I would have opted for external beam radiation or some other treatment rather than trust my fate to these guys who seem so incredibly slow to master this technique.

But then I've been in Mexico for two weeks, and the sun and tequila may have scrambled my brains.

Posted 2/17/2011 7:19 PM (GMT 0)
clock,
All things relative, we have been stressing here at HW that experience matters. But it does not matter if we are talking about robotic, open, radiation, cryo, etc. You can make a mistake by not asking your RO how much experience he has with prostate cancer. I think the article is a bit on the high side in recommended experience, but i certainly agree with the article that there are indeed a lot of urologists practicing surgery that should not be doing so. And probably none will admit it. Our best option as patients is to obtain the surgeon with the highest possible number of surgeries as experience will get you through a lot of complications.

When I speak tonight before the surgeon takes the stage I will stress that a patient has his own responsibility to do the best they can to help avoid complications from surgery. One of the things they can do if they selected surgery is go the extra mile and verify experience of the surgeon. I myself do not have SE's that most here do, but I knew the surgeon was very reputable. This not only matters in the complications but also an experienced surgeon will also be able to increase your chances of a good outcome in fighting cancer.

All you newbies ~ this is extremely important information...

Tony
Posted 2/17/2011 7:31 PM (GMT 0)
Tony, I certainly won't argue against the value of experience.

However, it still seem to me that if it takes 1600 procedures to become truly proficient at DaVinci surgery, then perhaps we've gone down a bad path.  We're talking about human lives and human futures, and if men are being directed toward a surgical procedure where hardly anyone meets these proficiency requirements, then maybe we need to take a second look at that.

Maybe we'd be better off doing all open surgeries, where I'm sure experience still matters a lot, but where I'd wager no one is saying it takes anything like 1600 procedures to become proficient.

I will also say that my relatively "inexperienced" surgeon spent an extra hour repairing some intestinal adhesions that he found while doing the DaVinci procedures.  Do you think the high volume guys would have done that, knowing they have maybe 3 more surgeries scheduled for that day?

Rather than directing everyone to a couple dozen docs who have 1600 surgeries under their belt, I'd feel better telling them to look at other options.  Maybe you can mention at the meeting that at least one guy on the forum seriously questions the high number and wonders just what they learned after, say, the 700th surgery that they hadn't known prior to that.  :)

Posted 2/17/2011 7:37 PM (GMT 0)
If you can do it without putting him on the spot, why not ask Dr. Wilson. As you know, he was my surgeon also, and while he's over 2000 now, he was "only" at about 1200 when he worked on me, and less than that when he worked on you. Of course I was very happy with 1200! I would think that he would say that 1600 is on the high side.

DJ
Posted 2/17/2011 7:43 PM (GMT 0)

The comment that my Uro said when I asked him about his experience as compared to others was this. 

He said that some surgeons find it difficult to transition from the open method to the robotic method.  And, they never quite seem to get comfortable with it.  While other surgeons transition from open to robotic easily and quickly.

He was one of the surgeons that transitioned easily and quickly.

Posted 2/17/2011 8:40 PM (GMT 0)
DJ,
I will indeed ask Tim that question. It's already on my list. Another question for him is whether he feels anymore comfortable with the procedure since my surgery 4 years ago (to the day).

Clock and all:
I think too much is being made of the 1600 number. The article emphasis is on experience and probably anything over a 1000 is good practice and 1,600 is best practice. I believe that a surgeon with over 1,600 RALP's is very rare and you have to start looking at surgeons in a major center practicing the procedure. Remember their experience get's handed to the doctors also working in the facility and what we don't know is if that shortens the learning curve.

Here is the abstract of the study in question:
www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confid=104&abstractid=72436

Tony
Posted 2/17/2011 8:57 PM (GMT 0)
What about the downside of doing more than 1000? Does the doc become blasé? Does the mind wander? "Only 3 more of these to do today and I can go to the staff party." "Which patient is this? Is he number 2 or 3 today? Is he the one with the high PSA that's taking the chance or is he the one with the family history?"
Do anything more than 1000 times and it begins to blur. (Just like women. I can't remember #1004 from #1006.)

Can the high success be related to something that is not just the number? How about this theory: The successful docs get more patients referred to them so their numbers go up? Or, the docs with high numbers are in their 40's and 50's and are more stable and don't go out partying the night before.

As clocknut pointed out if it really takes 1600 operations to become proficient then we have a serious problem with the method. We're not baking pancakes here. It is not OK to throw out the first ones just to get the pan ready.

Here's a real innovative idea. How about turning on the 1 TB hard drive plugged into the back of the DaVinci and have it record the camera video and offer the 2 hour CD to the patient as part of his record? That way the patient can see exactly what happened. Was the Cowper's Gland spared? Was that nerve really spared? Did you lose half your bladder sphincter and will be incontinent? The patient can plan his recovery accordingly.

I would go to any surgeon who had the balls confidence to offer that service to a patient. That surgeon would have 1000 notches under his belt in no time.

Jeff
Posted 2/17/2011 9:19 PM (GMT 0)
Surgeons are like athletes, engineers, etc. Unfortunately, unlike the others who's results can be judged objectively, there is no objective posting of the skills/results of the surgeons other than how many surgeries they performed, or word of mouth from satisfied patients. I stayed away from a number of surgeon candidates who my gut told me were not suitable for me but really had no way of knowing. It is really a crap shoot. Medicine should not be that way!

Now that I have more time to research, I am starting to think radiation is perhaps less skill dependence and if I were to do it over, I would look at radiation more seriously. Any of you folks have opinions on this?
Posted 2/17/2011 9:39 PM (GMT 0)
Here's what I've learned.

The author is the junior partner to Dr. Tewari, of Columbia Presbyterian / Weill Cornell Hospital in NYC. Tewari is real good, does 3-4 robotic's a day. Every day. For 5-6 years.

Very, very few docs have done as many. Maybe Samadi is the only doc to have done more.

Seems to me that all the recent competition has the "prostatectomy factory" at Weill Cornell a bit concerned.

Gotta protect what is yours, no?
Posted 2/17/2011 10:11 PM (GMT 0)
Even if the "proficiency bar" is lowered to 1000 surgeries, and if there are maybe 30 docs in the USA who have done that many, that means that 30,000 men have had DaVinci procedures peformed by surgeons whose level of proficiency might be called into question.

That is absolutely disturbing to consider, because as was said above, we aren't pancakes.  We're human beings.  Either the mechanics of the procedure are too hard, or the surgeons are slow leaners, methinks.

Posted 2/17/2011 10:13 PM (GMT 0)
Guys, this is the trouble with still another silly study. Where did the 1600 number come from? Could it really be the 1347th one, or the 203rd operation? A very subjective number at best. And, folks forget, its not just a number games, oh, let's pick the surgeon with the most surgeries. That surgeon might suck on a case by case bases, yet another surgeon with half his numbers might be excellent. Sometimes, and I have seen this with new guys, they think you can just pick a good surgeon out of a catalog based on his "specs". This isn't like buying a car or a washing machine. What is the doctor's real reputation like? What kind of followup does he/she do? Is he/she in it for the whole distance with you if things go wrong? Etc, etc.

I personally (prepared to be stabbed or shot) don't think that robotic surgery is always in the patient's best interest, but in the best interest of the hospital tooting their horn and paying back the expensive hardware, and in the surgeon's hands to make things easier for him. There is still a lot to be said for open surgery in the hands of a skilled surgeon that just isnt going to be replaced with a robot.

David in SC
Posted 2/17/2011 10:44 PM (GMT 0)
Basically what this study showed was that performance, measured by the rate of positive margins, increased as experience increased. The rate flattened somewhere around 1,000 and continued to improve at a slower rate untill 1,600.
Why is this so difficult to believe? The rule of thumb for most things requiring a high level of skill is the "magic" 10,000 repeats before one becomes a skilled expert.
No one believes one can be a professional golfer or baseball player if he has only played 50 games, yet we believe a surgeon can become proficient after 30 or 40 surgeries.
We have countless studies from many institutions that say the most experienced doctors get the best results. This is very useful information for us patients and you can ignore it if you want.

In this disease we don't have a lot of control, but choosing the best doctor possible is one of the few things we can control that will significantly add to a more favorable outcome. As I've said many times the doctor you choose will have more impact on your outcome than the treatment you choose.

JT
JT
Posted 2/17/2011 10:55 PM (GMT 0)
The most experienced uro in my area performs about 50 daVinci surgeries per year.  This means he will become proficient in about 30 yrs or around 2041.  What's one to do?

Carlos

Posted 2/17/2011 11:36 PM (GMT 0)
Hi Carlos,

Drive, fly, take a train to a place where you can get a surgeon with more experience. It may be a little inconvinient but 4 years from now the minor inconvinience would be a distant memory.
As John said, it's one of the few things you can control.

An
Posted 2/18/2011 12:20 AM (GMT 0)
If the Cyberknife people can put up billboards and advertise on the radio, why don't Robotic Prostate Surgeons do the same thing?? They could put their numbers, their percentages right up there in lights for all to see..Why keep this stuff secret..What are we supposed to do?? Hire a private detective to check these guys out??

Lets do some numbers crunching..90,000 men get Radical Prostatectomies. every year...450 "EXPERT" surgeons would be needed, each doing 200 a year, 5 a week for 40 weeks a year. At $10,000 a pop, that would provide them with $2,000,000 / year income.. 450 surgeons is enough for 9 in each state. Some states would have more, some less, according to population and surgical demand..

Problem solved. Except for choosing the 450 surgeons...
Posted 2/18/2011 6:16 AM (GMT 0)
i just returned home from dropping Dr. Wilson off at the airport. I was able to get him to check in on this topic while we were at dinner.

At the City of Hope when they began the program the learning curve is as follows with DaVinci Surgery:

<50 procedures the RALP took 6.7 hours.
50-100 4.2 hours
100-250 3.5 hours
>250 2.5 hours

He stated that experience absolutely matters and that when the surgeon is with another surgeon that has 800+ procedures the learning curves are much faster. He fully acknowledged that 800 is an important number at least in his experience. He does not feel that the next 1200 procedures made him a better surgeon but rather it's important to note that the current version of DaVinci might be a factor. Currently version 4 is the latest version of DaVinci and it absolutely will reduce the learning curves. Much of this is due to finer control movement and high definition screens. He said to look at it like televisions. 10 years ago DaVinci was done on CRT screens. Today LED 1080i and 1080P, through lenses, are far superior thus you are able to zoom and focus more definitively. Additionally, the control arms of the robot respond to finer movement and the machine in zoom modes will also adjust the arm movements according to the magnification that has been greatly improved.

He stated that the numbers in this study would limit prostate cancer surgery to less than 20 doctors with that skill level in the world. He did not believe that would prove correct when adding more facilities into the study with DaVinci Ver 4.

He also took the time to address this study in the meeting and was very positive about it. He laughed and said it stirs the surgeon community up a little and that's not necessarily a bad thing.


Fairwind,
He also brought up a point that might make you cringe. He stated that Urologists need to stay out of the radiation oncology business. While CoH has such a program, the costs of radiation are exponentially higher and so are the profits. And they can pile 20 guys a day though a single Tomotherapy or IMRT system.

Needless to say, Dr Wilson was a great speaker. In fact we had a urologist from the Las Vegas are in attendance and I can tell you that I have regularly had a tough time getting them to come. But the local guys said he will in fact help our group and volunteer his time and send patients.

It was a good day at our meeting. We had 50 folks in attendance.

Tony
Posted 2/18/2011 6:19 AM (GMT 0)
One more note. Davinci was just approved in Japan for RALP. He was brought in by the Japanese medical groups to oversee the clinical trials and provide training. He said there are 19 Davinci machines in Japan for 100 million people. In the US there are 300 million people and 1,900 devices.

Just an interesting note...

Tony
Posted 2/18/2011 3:22 PM (GMT 0)
This is a very interesting discussion for sure. Once I decided on the da Vinci procedure, I actually scheduled two separate surgery dates with two different surgeons because I hadn't decided on which one I was going to go with yet (but I wanted to secure a date). I had a high confidence level in both surgeons.

One of the reasons I selected the one I went with is because his assistant surgeon is not an MD, but a da Vinci robotic expert. I called his office and learned that he assists all different types of surgeons that use the da Vinci system.

I did end up selecting the surgeon with the most experience for this as well as other reasons. And now, at about 3 1/2 weeks out, so far so good.

Regarding the post about the Japanese approving the da Vinci RALP procedure; I remembering reading that PCa incidence was very low to non-existent for Asians that eat an Asian diet. I wonder how much they will even being doing this.

Also, where can I find more information regarding the Las Vegas PCa meetings? I live about 300 miles away and may be interested in driving over for one of these.
Posted 2/18/2011 8:30 PM (GMT 0)
axle,
The UsTOO Las Vegas Chapter meets every third Thursday of the month at the Nevada Cancer Institute auditorium at 7:00pm. We don't meet in July or December. On March 17 we have one of the premier prostate cancer researchers in the country in Nick Vogelzang speaking about the ASCO Genitourinary Oncology Symposium that is releasing all these interesting goodies to us this week. He'll also talk about the clinical trials that he is the head doc on. He is one of my best speakers but I am biased. He is my oncologist as well.

You, and anyone here, are most welcome.

Tony
Posted 2/18/2011 9:02 PM (GMT 0)
Tony,

Thanks for reporting on what Dr. Wilson talked about. Sounds like you run a pretty good group there in LV.

DJ
Posted 2/18/2011 10:45 PM (GMT 0)
That number is rediculous.

What happens, all of a sudden on the 1600 they get it right.

Garbage.

"My guy did a zillion so he's the best"

"My guy is the best know my result was better"

 

Nonsense.. that's all about doctors trying to make like they have some special talent that equzally trained doctors dont. And patients who want to pat themselves on the back because THEY were smarter then the other guy.

I'd bet that 80%+ of the time ALL of it has to do with your age, the type of pca, stage, luck, and god. 

There are no doctors with magic eyes or hands. Gods are for your nexxt journey, not this one.

Posted 2/18/2011 11:57 PM (GMT 0)
GTOdave,
I missed your post. Just a note...The pioneer on the robotic system is Dr. Mani Menon. He also have performed more DaVinci's, according to Dr. Wilson, than any other doctor at over 4,000. Next would probably be Dr. Vijay Patel. Tewari and Samadi do quite a few themselves. Out on the west coast it's Marc Kawachi and Tim Wilson as the most experienced.

Tony
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